Refusal to eat in the elderly

Experiences, Personal Attitudes, and Professional Stances of Swiss Health Care Professionals Toward Voluntary Stopping of Eating and Drinking to Hasten Death: A Cross-Sectional Study

CONTEXT

Voluntary stopping of eating and drinking (VSED) is the self-determined decision of an individual with the decision-making capacity to cause premature death. During the course of VSED, the person is dependent on the support of relatives and health professionals. To date, little is known of the attitudes of Swiss health professionals on this topic.

OBJECTIVES

The objective of this study was to assess the experiences, personal attitudes, and professional stances of Swiss health care professionals toward VSED.

METHODS

We conducted a nationwide cross-sectional survey by questioning family physicians and the heads of outpatient care and long-term care (e.g., nursing directors, institute directors, or head nurses) about VSED (n = 1681; response rate 40.1%). Descriptive data analysis and hypothesis testing (occupational group, age, sex, professional years, VSED experience, and regions) were subsequently conducted.

RESULTS

Individuals who are willing to die are granted the right to professional accompaniment during VSED (agreement 97.8%), and their death is usually classified as a natural form of dying (63.5%) and only rarely (5.4%) as suicide. Family physicians have significantly more moral concerns during accompaniment compared with the heads of outpatient and long-term care (P < 0.001).

CONCLUSION

Swiss health care professionals support the autonomy and self-determination of patients, which is also reflected in their positive attitude toward VSED, even if they have moral reservations when accompanying patients.

Potential proton pump inhibitor-related adverse effects

Proton pump inhibitors (PPIs) are one of the most common medications taken by patients worldwide. PPIs are used to treat acid-related disorders, including gastroesophageal reflux disease, peptic ulcer disease, Helicobacter pylori infection, and nonsteroidal anti-inflammatory drug/stress ulceration. For some of these diseases, long-term treatment is necessary. With such prolonged use, concern and investigation into potential adverse effects has increased. In addition, data are available regarding potential anticancer effects of PPIs, especially regarding solid tumors. The aim of this review is to assess the literature on PPIs with regard to common concerns, such as drug-drug interactions, the intestinal microbiome, dementia and central nervous system disease, and osteoporosis, as well as to highlight potential negative and positive impacts of the drug in cancer.

Optimizing sensory quality and variety: An effective strategy for increasing meal enjoyment and food intake in older nursing home residents

A decline in appetite and consequently in food intake is often observed with ageing, particularly in older adults living in nursing homes. Several strategies have been tested in nursing homes to counter this phenomenon. However, the approaches have rarely focused on food improvement, and most studies have assessed the impact of flavor enhancement on eating behavior. The present experiment aimed to assess the impact of improving sensory quality versus increasing sensory variety on food intake and meal enjoyment in elderly individuals living in a nursing home. Four conditions were compared: control condition, a Quality+ condition (recipes were improved according to sensory preference of the target population), a Variety+ condition (participants were offered a variety of main dishes and several condiments throughout the meal) and a Quality&Variety+ condition combining the two previous conditions. Eighty-two residents (age range: 71-101 years) participated in eight lunchtime sessions (2 replicates × 4 conditions). Compared to control condition, our results showed that improving the sensory quality of the dishes and/or providing variety led to increased meal enjoyment and food intake (energy intake: +5% for Quality+; +7% for Variety+). No additional effect was observed when the two factors were combined (+7% for Quality&Variety+). These results suggest that meal improvement strategies can be used to increase food intake in order to prevent and treat malnutrition in dependent older adults.

The need to distinguish between different forms of oral nutrition refusal and different forms of voluntary stopping of eating and drinking

Voluntary stopping of eating and drinking (VSED) is a well-known phenomenon among palliative care professionals. This study intent to distinguish between different forms of VSED. In a qualitative interview study 18 relatives were interviewed about their experiences of caring a person during VSED. Different forms of oral nutrition refusal and different forms of VSED were found and described. The study results help members of the multidisciplinary team to manage the situation appropriately.

Thiamine Concentrations in Newly Hospitalized Elderly Patients with Infectious Diseases at a Community Hospital in Japan

The association between advanced age and the thiamine concentration has not been conclusively determined. A recent report from Japan showed that more than half of nursing home elderly residents at an institution had a low whole-blood thiamine concentration (<20 ng/mL). Therefore, a high incidence of low thiamine concentrations among hospitalized elderly has been anticipated in the Japanese population but never investigated. We evaluated the whole thiamine concentration in newly hospitalized elderly patients (≥65 y old) with infectious diseases. Evaluations were performed on admission and at days 6-8 of hospitalization with liquid chromatography tandem mass spectrometry (LC/MS/MS). As a result, we enrolled a total of 471 patients from September 2015 to December 2016. The median thiamine concentration was 46 ng/mL (IQR, 37-58 ng/mL). Only 7 patients (1%) had thiamine concentrations below 20 ng/mL (66 nmol/L) on admission. Five of these patients were bedridden and unable to eat food by themselves, and the other two patients used loop diuretics for chronic heart failure. The thiamine concentration declined in most patients (84%) at days 6-8 of admission, regardless of their dietary intake during hospitalization. In conclusion, a low thiamine concentration was not prevalent among newly hospitalized elderly patients with infectious diseases. However, the thiamine concentration significantly decreased during the 6-8 d of hospitalization.

Nutritional Status of Rural Older Adults Is Linked to Physical and Emotional Health

BACKGROUND

Although nutritional status is influenced by multidimensional aspects encompassing physical and emotional well-being, there is limited research on this complex relationship.

OBJECTIVE

The purpose of this study was to examine the interplay between indicators of physical health (perceived health status and self-care capacity) and emotional well-being (depressive affect and loneliness) on rural older adults' nutritional status.

DESIGN

The cross-sectional study was conducted from June 1, 2007, to June 1, 2008.

PARTICIPANTS/SETTING

A total of 171 community-dwelling older adults, aged 65 years and older, residing within nonmetro rural communities in the United States participated in this study.

MAIN OUTCOME MEASURES

Participants completed validated instruments measuring self-care capacity, perceived health status, loneliness, depressive affect, and nutritional status.

STATISTICAL ANALYSES PERFORMED

Structural equation modeling was employed to investigate the complex interplay of physical and emotional health status with nutritional status among rural older adults. The χ² test, comparative fit index, root mean square error of approximation, and standardized root mean square residual were used to assess model fit.

RESULTS

The χ² test and the other model fit indexes showed the hypothesized structural equation model provided a good fit to the data (χ² (2)=2.15; P=0.34; comparative fit index=1.00; root mean square error of approximation=0.02; and standardized root mean square residual=0.03). Self-care capacity was significantly related with depressive affect (γ=-0.11; P=0.03), whereas self-care capacity was not significantly related with loneliness. Perceived health status had a significant negative relationship with both loneliness (γ=-0.16; P=0.03) and depressive affect (γ=-0.22; P=0.03). Although loneliness showed no significant direct relationship with nutritional status, it showed a significant direct relationship with depressive affect (β=.4; P<0.01). Finally, the results demonstrated that depressive affect had a significant negative relationship with nutritional status (β=-.30; P<0.01). The results indicated physical health and emotional indicators have significant multidimensional associations with nutritional status among rural older adults.

CONCLUSIONS

The present study provides insights into the importance of addressing both physical and emotional well-being together to reduce potential effects of poor emotional well-being on nutritional status, particularly among rural older adults with impaired physical health and self-care capacity.

Case report of comorbid schizophrenia and obsessive compulsive disorder in a patient who was tube-fed for four years by family members because of his refusal to eat

Refusal to eat is a common presentation in many psychiatric disorders including obsessive compulsive disorder and schizophrenia. In the acute situation it may be a medical emergency; when it becomes chronic it can become an ingrained behavior that is difficult to change. The diagnosis of individuals who refuse to eat may be difficult, particularly in persons with comorbid medical problems, impaired intelligence, or lack of insight into their condition. Tube-feeding is an effective short-term intervention that can be discontinued when the patient re-starts oral intake. However, in some situations patients may become dependent on the use of tube-feeding. We present a case report of a patient with schizophrenia, obsessive compulsive disorder, borderline intelligence, and seizure disorder who was tube-fed by his family members for more than three years because he refused to eat orally.

The association between depression and widowhood and nutritional status in older adults

This study aimed to investigate the association of depression and widowhood on the nutritional status of older adults. A cross-sectional study of community-dwelling older adults in the rural United States was conducted. Dietary intake was measured via questionnaires. Depression status was classified by asking participants if they have ever been diagnosed with the condition, or by review of medical records. The final sample consisted of 1065 participants with 141 (13.2%) depressed, 384 (36.1%) widowed, and 67 (6.3%) both depressed and widowed. Mean caloric intake for total study population was low; widows and widowers had the lowest energy consumption among all groups. Greater intake of several nutrients was observed in depressed and/or widowed subjects. Nutritional services, such as congregate and home delivered meal programs, were not identified as significant contributors to the nutritional intake in older adults who were depressed, widowed, or both. Health care professionals may contribute to meal-based nutrition programs by offering their assistance in aspects of nutritional education and counseling for the promotion of healthy aging.

Anorexia and eating patterns in the elderly

Objectives

To evaluate the change in eating habits occurring in community- dwelling and institutionalized elderly subjects with senile anorexia.

Design

Cross- sectional, observational.

Setting

Community, nursing homes and rehabilitation or acute care facilities in four Italian regions.

Participants

A random sample of 526 subjects, aged 65 years and older (217 free living individuals, 213 residents in nursing homes, and 93 patients in rehabilitation and acute wards).

Measurements

All subjects underwent a multidimensional geriatric evaluation of: nutritional status, anthropometric parameters, health and cognitive status, depression, taste, chewing and swallowing function, and some hormones related to appetite. Diet variety was assessed, considering the frequency of consumption of different food groups (milk and dairy products; meat, fish, and eggs; cereals and derivatives; fruit and vegetables).

Results

In anorexic elderly subjects the global food intake was reduced, and the eating pattern was characterized by the reduced consumption of certain food groups (“meat, eggs and fish” and “fruit and vegetables”) whereas the frequency of consumption of milk and cereals remained almost unchanged. Nutritional parameters were significantly better in normal eating subjects and correlated with diet variety.

Conclusion

Because of the high prevalence of senile anorexia in the geriatric population and its impact on the nutritional status, further research should be prompted to establish an intervention. protocol allowing the early diagnosis of anorexia of aging, aimed at identifying its causes and at optimizing treatment of anorexic patients.

Malnutrition in elderly: social and economic determinants

Malnutrition occurs frequently in the frailest groups of the population, especially in people who are on a low income and elderly subjects, overall if they are institutionalized. The aim of this study was to assess the prevalence of malnutrition in a sample of elderly people living in different settings and to identify the determinants of malnutrition.

METHODS

A total of 718 subjects, 472 females (F) and 246 males (M), were recruited from nursing homes or were free living in three different regions in Italy. Nutritional status, depression, social, functional and cognitive status, were evaluated.

RESULTS

According to the Mini Nutritional Assessment (MNA), a high prevalence of malnutrition was found out in both genders: 26% of F and 16.3% of M were classified as being malnourished (MNA<17); 40.9% of F and 35% of M were at risk of malnutrition (MNA 17-23,5). The prevalence of malnutrition was significantly higher in NH subjects in both sexes. Moreover, a relationship was shown between malnutrition and inability to shop, prepare and cook meals because of a low income, distance from markets or supermarkets as well as impossibility to drive the car or to use public transportation. This study confirms the necessity to routinely perform nutritional status evaluation in elderly subjects, to carry out training courses for health workers (doctors, nurses, psychologists, dietitians), to implement nutritional education of the geriatric population, to develop tools and guidelines for health workers and caregivers, to identify and reduce clinical, functional, social or economic risk factors for malnutrition.

Hardiness, depression, and emotional well-being and their association with appetite in older adults

OBJECTIVES

To examine the associations between hardiness (defined as the ability to manage stress), depression, and emotional well-being and appetite in older adults.

DESIGN

Cross-sectional.

SETTING

Assisted-living facilities and senior centers in the Washington/Baltimore area.

PARTICIPANTS

Two hundred ninety-two adults aged 60 and older.

MEASUREMENTS

Depressive symptoms assessed using the 5-item Geriatric Depression Scale and categorized as 0 to 1 (normal, referent group) versus 2 to 5 (depressive symptoms present). Hardiness was measured using the 18-item Dispositional Resilience Scale II modified based on interviews with older adults and categorized as 67 or less (low hardiness) versus greater than 67 (normal, referent group). Appetite was measured using the Simplified Nutritional Appetite Questionnaire and categorized as 4 to 14 (poor appetite) versus 15 to 20 (normal, referent group). Emotional well-being was measured using a single question.

RESULTS

Depression, hardiness, and emotional well-being were all significantly associated with appetite. In models controlling for confounders (data collection site, age, educational attainment, self-reported health, race, presence of chronic disease), fair to poor emotional well-being was most significantly associated with poor appetite (odds ratio (OR)=5.60, 95% confidence interval (CI)=2.60-12.07) and low commitment (a component of hardiness that indicates an individual's involvement in life) was also significantly associated with poor appetite (OR=1.35, 95% CI=1.13-1.61).

CONCLUSION

These associations further elucidate the components of mental health that contribute to poor appetite in this population. Simple measures of self-reported mental health administered to older adults may predict poor appetite and lend themselves to potential interventions to prevent malnutrition and negative health outcomes.

The changing face of food and nutrition in Canada and the United States: opportunities and challenges for older adults

Science and technology are modernizing the field of nutrition and are consequently increasing its complexity. New food developments such as fortified foods and functional foods are evidence of its modernization. The increased specificity of nutrient- and food-intake recommendations and the breadth of claims on food packages are evidence of nutrition's growing complexity. Unfortunately, research on the consumer acceptability of new food developments and nutrition education initiatives has not kept pace with advancements in the field. This is especially true for older adults, a subgroup of the population that appears to be under-researched and not commonly targeted with education initiatives. Older adults are the fastest growing segment of the North American population. Research and education aimed at this demographic is warranted to ensure older adults have the right knowledge and skill set to optimize their food selections and dietary patterns with the possibility of improving health and the quality and longevity of life.

Folic acid with or without vitamin B12 for the prevention and treatment of healthy elderly and demented people

BACKGROUND

Folate deficiency can result in congenital neural tube defects and megaloblastic anaemia. Low folate levels may be due to insufficient dietary intake or inefficient absorption, but impaired metabolic utilization also occurs.Because B12 deficiency can produce a similar anaemia to folate deficiency, there is a risk that folate supplementation can delay the diagnosis of B12 deficiency, which can cause irreversible neurological damage. Folic acid supplements may sometimes therefore include vitamin B12 supplements with simultaneous administration of vitamin B12.Lesser degrees of folate inadequacy are associated with high blood levels of the amino acid homocysteine which has been linked with the risk of arterial disease, dementia and Alzheimer's disease. There is therefore interest in whether dietary supplementation can improve cognitive function in the elderly.However, any apparent benefit from folic acid which was given in combination with B12 needs to be "corrected" for any effect of vitamin B12 alone. A separate Cochrane review of vitamin B12 and cognitive function has therefore been published.

OBJECTIVES

To examine the effects of folic acid supplementation, with or without vitamin B12, on elderly healthy or demented people, in preventing cognitive impairment or retarding its progress.

SEARCH STRATEGY

Trials were identified from a search of the Cochrane Dementia and Cognitive Improvement Group's Specialized Register on 10 October 2007 using the terms: folic acid, folate, vitamin B9, leucovorin, methyltetrahydrofolate, vitamin B12, cobalamin and cyanocobalamin. This Register contains references from all major health care databases and many ongoing trials databases. In addition MEDLINE, EMBASE, CINAHL, PsychINFO and LILACS were searched (years 2003-2007) for additional trials of folate with or without vitamin B12 on healthy elderly people.

SELECTION CRITERIA

All double-blind, placebo-controlled, randomized trials, in which supplements of folic acid with or without vitamin B12 were compared with placebo for elderly healthy people or people with any type of dementia or cognitive impairment.

DATA COLLECTION AND ANALYSIS

The reviewers independently applied the selection criteria and assessed study quality. One reviewer extracted and analysed the data. In comparing intervention with placebo, weighted mean differences and standardized mean difference or odds ratios were estimated.

MAIN RESULTS

Eight randomized controlled trials fulfilled the inclusion criteria for this review. Four trials enrolled healthy older people, and four recruited participants with mild to moderate cognitive impairment or dementia with or without diagnosed folate deficiency. Pooling the data was not possible owing to heterogeneity in sample selections, outcomes, trial duration, and dosage. Two studies involved a combination of folic acid and vitamin B12.There is no adequate evidence of benefit from folic acid supplementation with or without vitamin B12 on cognitive function and mood of unselected healthy elderly people. However, in one trial enrolling a selected group of healthy elderly people with high homocysteine levels, 800 mcg/day folic acid supplementation over three years was associated with significant benefit in terms of global functioning (WMD 0.05, 95% CI 0.004 to 0.096, P = 0.033); memory storage (WMD 0.14, 95% CI 0.04 to 0.24, P = 0.006) and information-processing speed (WMD 0.09, 95% CI 0.02 to 0.16, P = 0.016).Four trials involved people with cognitive impairment. In one pilot trial enrolling people with Alzheimer's disease, the overall response to cholinesterase inhibitors significantly improved with folic acid at a dose of 1mg/day (odds ratio: 4.06, 95% CI 1.22 to 13.53; P = 0.02) and there was a significant improvement in scores on the Instrumental Activities of Daily Living and the Social Behaviour subscale of the Nurse's Observation Scale for Geriatric Patients (WMD 4.01, 95% CI 0.50 to 7.52, P = 0.02). Other trials involving people with cognitive impairment did not show any benefit in measures of cognitive function from folic acid, with or without vitamin B12.Folic acid plus vitamin B12 was effective in reducing serum homocysteine concentrations (WMD -5.90, 95% CI -8.43 to -3.37, P < 0.00001). Folic acid was well tolerated and no adverse effects were reported.

AUTHORS' CONCLUSIONS

The small number of studies which have been done provide no consistent evidence either way that folic acid, with or without vitamin B12, has a beneficial effect on cognitive function of unselected healthy or cognitively impaired older people. In a preliminary study, folic acid was associated with improvement in the response of people with Alzheimer's disease to cholinesterase inhibitors. In another, long-term use appeared to improve the cognitive function of healthy older people with high homocysteine levels. More studies are needed on this important issue.

Senile anorexia in acute-ward and rehabilitations settings

The most common pathological change in eating behaviour among older persons is anorexia, which accounts for a large percent of undernutrition in older adults. The main research aims are to determine, in a sample of acute and rehabilitation elderly subjects, the prevalence of anorexia of aging and the causes most impacting on senile anorexia.

METHODS

four different Units cooperated to this research study. Patients were recruited from geriatric acute and rehabilitation wards in Italy. Each Research Unit, for the estimation of the prevalence of anorexia in elderly subjects evaluated all the patients aged over 65 recruited from April 2006 to June 2007. Nutritional status, depression, social, functional and cognitive status, quality of life, health status, chewing, swallowing, sensorial functions were evaluated in anorexic patients and in a sample of "normal eating" elderly subjects.

RESULTS

96 anorexic subjects were selected in acute and rehabilitation wards (66 women; 81.5 +/- 7 years; 30 men: 81.8 +/- 8 years. The prevalence of anorexia in the sample was 33.3% in women and 26.7% in men. Anorexic subjects were older and more frequently needed help for shopping and cooking. A higher (although not statistically significant) level of comorbidity was present in anorexic subjects. These subjects reported constipation and epigastrium pain more frequently. Nutritional status parameters (MNA, anthropometry, blood parameters) were significantly worst in anorexic subjects whereas CRP was higher. Chewing and swallowing efficiencies were significantly impaired and eating patterns were different for anorexic subjects with a significant reduction of protein rich foods.

CONCLUSIONS

consequences of anorexia can be extremely serious and deeply affect both patient's mobility, mortality and quality of life. Therefore, it is of utmost importance to perform a special evaluation of the nutritional risk, to constantly evaluate the nutritional status and feeding intake of older patients, to identify and treat the underlying disease when possible, to institute environmental and behavioural modifications, to organise staff better in order to produce higher quality feeding assistance during mealtimes, to plan early nutrition rehabilitation and nutritional education programs for caregivers. There is also the necessity to develop diagnostic procedures easy to perform, able to identify the pathogenesis of anorexia and, therefore, treatment strategies exactly fitting the patients' needs.

Peripheral ghrelin treatment stabilizes body weights of senescent male Brown Norway rats at baseline and after surgery

Unintentional weight loss may occur spontaneously in older humans and animals. Further weight losses after surgery or illness in the older patients result in increased morbidity, mortality, and hospital readmission rate. A growing body of work has shown increased appetite and weight gain in response to administration of ghrelin, the “hunger hormone.” We conducted two studies in senescent male Brown Norway rats to assess the ability of peripheral administration of ghrelin to increase body weight and food intake. One study assessed the effect of 2 wk of daily subcutaneous ghrelin administration (1 mg·kg−1·day−1) to senescent rats in a baseline condition; a second study used the same administration protocol in an interventional experiment with aged rats subjected to a surgery with 10–15% blood loss as a model of elective surgery. In both studies, animals receiving ghrelin maintained their body weights, whereas control animals lost weight. Body weight stability was achieved in ghrelin-treated animals despite a lack of increase in daily or cumulative food intake in both experiments. Hormone and proinflammatory cytokine levels were measured before surgery and after 14 days of treatment. Ghrelin treatment appeared to blunt declining ghrelin levels and also to blunt cytokine increases seen in the surgical control group. The ability of peripheral ghrelin treatment to maintain body weights of senescent rats without concomitant increases in food intake may be due to its known ability to decrease sympathetic activity and metabolic rate, perhaps by limiting cytokine-driven inflammation.

Nursing Home Food Services Linked with Risk of Malnutrition

Purpose: Links between food service characteristics and residents’ risk of malnutrition were examined.

Methods: Cognitively intact residents meeting inclusion criteria and living in one of 38 participating nursing homes were randomly sampled. The final sample consisted of 132 residents, who were screened for risk of malnutrition and completed a face-to-face interview questionnaire about dining experiences. Additional data came from participants’ medical charts, and each institution's food service manager completed a written questionnaire. Frequencies and logistic regressions were used to describe the sample and to examine relationships between risk of malnutrition and food service characteristics.

Results: Overall, 37.4% of participants were at risk of malnutrition. Food service factors, including food packages, lids, and dishes that were difficult to manipulate (β=0.285, p=0.009), bulk food-delivery systems (β=1.329, p=0.036), overall food satisfaction (β=0.253, p=0.044), menu cycle length (β=-2.162, p=0.003), and porcelain dishes (β=-0.345, p=0.052), all were significantly associated with risk of malnutrition.

Conclusions: Our findings clearly show a need for nursing homes to modify certain aspects of food service that may increase the risk of malnutrition among cognitively intact residents.

Mechanisms of the anorexia of aging in the Brown Norway rat

Aging is associated with a loss of the ability to maintain homeostasis in response to physiologic and environmental disturbances. Age-related dysregulation of food intake and energy balance appears to be the result of impaired responsiveness of hypothalamic integrative circuitry to metabolic cues, which can lead to lack of appropriate food intake (the anorexia of aging) and thus to inappropriate weight loss in response to acute or chronic illness or other stressors. Using the Brown Norway (BN) male rat model, we have shown that old animals fail to appropriately increase food intake after the metabolic challenge of a 72 h fast, resulting in the failure to re-gain lost body weight upon refeeding. Leptin levels increase with adiposity and age, and remain elevated above levels of young animals even after a 72 h fast, suggesting that hyperleptinemia may be influencing the energy balance dysregulation. It is unclear whether this age-related response is due to a failure of the network of hypothalamic neurons to appropriately integrate hormonal and neural inputs, or due to a failure of the neurons to produce the appropriate neuropeptides. We hypothesize that sequential, age-related alterations in the expression patterns of neuropeptides that maintain melanocortinergic tone, and in the hormone mediators that inform the system of the state of energy balance, result in a diminished ability to maintain energy homeostasis with increasing age. We have undertaken a number of interventional approaches to test this hypothesis, including manipulations of the hormones ghrelin, insulin and testosterone, and direct application of neuropeptides to the central nervous system in these animals.

ESPEN Guidelines on Enteral Nutrition: Geriatrics

Nutritional intake is often compromised in elderly, multimorbid patients. Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and tube feeding (TF) offers the possibility to increase or to insure nutrient intake in case of insufficient oral food intake. The present guideline is intended to give evidence-based recommendations for the use of ONS and TF in geriatric patients. It was developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. The guideline was discussed and accepted in a consensus conference. EN by means of ONS is recommended for geriatric patients at nutritional risk, in case of multimorbidity and frailty, and following orthopaedic-surgical procedures. In elderly people at risk of undernutrition ONS improve nutritional status and reduce mortality. After orthopaedic-surgery ONS reduce unfavourable outcome. TF is clearly indicated in patients with neurologic dysphagia. In contrast, TF is not indicated in final disease states, including final dementia, and in order to facilitate patient care. Altogether, it is strongly recommended not to wait until severe undernutrition has developed, but to start EN therapy early, as soon as a nutritional risk becomes apparent.

Nutritional factors, cognitive decline, and dementia

Nutritional factors and nutritional deficiencies have been repeatedly associated with cognitive impairment. Most of the evidence is based on cross-sectional studies, which cannot prove whether a nutritional deficit is the cause or the consequence of an impaired cognitive status. In fact, cognitive impairment, in turn, can determine changes in dietary habits and consequent nutritional deficiencies. We reviewed clinical and epidemiological studies from January 1983 to June 2004. Several cross-sectional and fewer prospective studies reported an association between dietary or supplemental intake of antioxidants and protection from cognitive decline and dementia. There are negative reports as well and some methodological biases might have affected the consistencies across studies. Deficiencies of several B vitamins have been associated with cognitive dysfunction in many observational studies. More recently, deficiencies of folate (B9) and cobalamine (B12) have been studied in relation to hyperhomocysteinemia as potential determinants of cognitive impairment, dementia, and Alzheimer's disease (AD). A small number of studies assessed the association between intake of macronutrients and cognitive function or dementia. Among the others, the intake of fatty acids and cholesterol has received particular attention. Although the results are not always consistent, most studies have reported a protective role of dietary intakes of poly- and mono-unsaturated fatty acids against cognitive decline and AD. We point out that well designed intervention studies are warranted in order to establish specific levels of micro- and macronutrient deficiencies and to set general recommendations for the population.

Behavioral Disturbances, Not Cognitive Deterioration, Are Associated With Altered Food Selection in Seniors With Alzheimer's Disease

OBJECTIVE

We previously reported alterations in circadian patterns of food intake that are associated with measures of functional and cognitive deterioration in seniors with probable Alzheimer's disease (AD). This study further explored disturbed eating patterns in AD, focusing on alterations in macronutrient (protein, carbohydrate, and fat) selection, and their association with measures of functional and behavioral losses.

METHODS

Forty-nine days of food intake collections were conducted on 32 residents (26 females, 6 males; age = 88.4 +/- 4.1 years; body mass index = 24.1 +/- 4.0 kg/m(2)) with probable AD residing at a nursing home (a fully accredited geriatric teaching facility affiliated with the University of Toronto's Medical School). All residents ate their meals independently. The relationships between patterns of habitual food consumption and measures of cognitive function (Severe Impairment Battery), behavioral disturbances (Neuropsychiatric Inventory-Nursing Home Version) and behavioral function (London Psychogeriatric Rating Scale) were examined, cross-sectionally.

RESULTS

Consistent with our previous studies, breakfast intakes were not predicted by any of the measures of behavioral, cognitive, or functional deterioration, although those residents with greater functional deterioration, especially disengagement, attained lower 24-hour energy intakes. The presence of "psychomotor disturbances," including irritability, agitation, and disinhibition, were strongly associated with shifts in eating patterns toward carbohydrate and away from protein, placing individuals with these conditions at increased risk for inadequate protein intakes. Between-individual differences in intake patterns could not be explained by the use of either anorexic or orexigenic medications.

CONCLUSIONS

Behavioral, not cognitive, deterioration is associated with appetite modifications that increase risk of poor protein intake, perhaps indicating a common monoaminergic involvement.

Is Chronic Nonmalignant Pain Associated with Decreased Appetite in Older Adults? Preliminary Evidence

OBJECTIVES

To examine the association between self-reported appetite impairment and pain intensity in community-dwelling older adults with chronic nonmalignant pain.

DESIGN

Cross-sectional survey.

SETTING

An outpatient pain clinic at the University of Pittsburgh.

PARTICIPANTS

A convenience sample of 65 older adults with chronic nonmalignant pain.

MEASUREMENTS

Demographics, pain intensity (short-form McGill Pain Questionnaire), self-reported appetite impairment using a newly developed instrument, mood (30-item Geriatric Depression Scale, (GDS)), cognitive status (Folstein Mini-Mental State Examination), dependence in feeding, dependence in grocery shopping and meal preparation, and comorbidities (Cumulative Illness Rating Scale). Medication information was classified as total number of medications, number of analgesics, number of opioids, and number of potential appetite-impairing side effects.

RESULTS

Univariate analyses revealed that those who reported pain-related appetite impairment had higher pain intensity than those who reported no appetite impairment (P<.001). Comparison of subjects with and without pain-related appetite impairment revealed a significant difference in GDS scores (P=.027), number of analgesics (P=.015), and number of opioids (P=.014). None of the other variables was statistically significant. The relationship between pain intensity and perceived pain-related appetite impairment was maintained in an analysis of covariance that controlled for GDS score, number of analgesics, and presence of opioids (P=.004).

CONCLUSION

Chronic pain is associated with self-reported appetite impairment in older adults, but examination of the influence of reduction in pain intensity on appetite improvement is needed to establish a causal relationship between chronic pain and diminished appetite.

Percutaneous endoscopic gastrostomy in cognitively impaired older adults: a geropsychiatric perspective

The increasing use of percutaneous endoscopic gastrostomy (PEG) in cognitively compromised elderly presents complex treatment-related and ethical questions. Approximately half of all dementia patients will be unable to feed themselves within eight years of their diagnosis. Moreover, 85 percent of dementia patients have demonstrated refusal to eat. Geropsychiatry is often employed to evaluate these cognitively impaired patients either prior to or following PEG tube placement. This manuscript presents three cases to illustrate the most commonly encountered general dementia presentations: the ability to communicate with decisional capacity, the ability to communicate without decisional capacity, and severe verbal aphasia without decisional capacity. The study discusses ethical issues and treatment strategies for pre- and post-PEG tube placement consultations, including environmental interventions, in order to improve quality of life for this population.

Prevention of weight loss in dementia with comprehensive nutritional treatment

OBJECTIVES

To determine whether body weight can be maintained or improved in dementia residents of special care units (SCUs) using a comprehensive intervention strategy.

DESIGN

Quasi-experimental with an interventional site and a noninterventional site.

SETTING

Four SCUs in two long-term care facilities in Ontario.

PARTICIPANTS

The intervention site included 33 residents; the comparison site included 49 residents.

MEASUREMENTS

Weight change over time was the primary outcome. Three time periods were compared: 9-month baseline period, 9-month intervention period (enhanced dietitian monitoring and menu changes at intervention site), and 12-month postintervention period (only menu changes at intervention site). Comparisons were made within and between sites. Full nutritional assessments were completed for the intervention group. Medical charts and basic anthropometric, behavioral, and cognitive measures were completed in both groups to determine baseline site differences. Weight change over time was analyzed with a repeated measures analysis, controlling for various covariates. Bivariate analyses were completed for other outcomes of death, number of infections, falls, and hospital days.

RESULTS

The intervention period that included the dietitian time and menu changes significantly promoted weight gain, compared with the standard treatment at the comparison facility. Other covariates of pacing, type of dementia, sex, age, number of comorbid conditions, and medications were also significant predictors of weight change. Weight gain or maintenance regardless of site was associated with survival.

CONCLUSION

Body weight can be maintained in residents of SCUs regardless of pacing and other clinical characteristics. The comprehensive intervention of clinical dietitian time and an enhanced menu designed to be individualized for ambulatory people with dementia promoted significant gains in body weight. A minimum 5% weight gain is associated with survival in these residents of SCUs.

Medical nutrition therapy for the prevention and treatment of unintentional weight loss in residential healthcare facilities

OBJECTIVES

To identify the rate of unintentional weight loss (UWL) in adults following their admission into residential healthcare facilities, assess the effectiveness of a new medical nutrition therapy (MNT) protocol for the prevention and treatment of UWL, and describe nutrition assessment and intervention activities of dietitians.

DESIGN

Prospective intervention study in which volunteer dietitians were randomly assigned to usual nutrition care (UC) or MNT protocol care (MNT-PC) groups. Dietitians recruited newly admitted residents and tracked their weights for up to 6 months using standardized weighing procedures. Data on weight outcomes and nutrition care activities were abstracted from medical records and compared between study groups. Subjects/settings Thirty-one dietitians from 29 facilities completed the field test (16 MNT-PC, 13 UC). Medical record data were available for 394 residents (223 MNT-PC, 171 UC), and complete weight trend data were available for 364 residents (200 MNT-PC, 164 UC).

INTERVENTION

The new MNT protocol for UWL in residential facilities emphasized assessment; intervention (including weighing frequency); communication with staff, medical doctor, family, and resident; and reassessment. Main outcome measures Rate of UWL and weight status 90 days after admission and weight status 90 days after identification of UWL. Statistical analyses Chi;(2), Independent t test, analysis of variance, and multiple regression using the general linear model.

RESULTS

Fourteen of 364 residents (4%) were admitted with significant preexisting weight loss, which was successfully treated in eight residents during the first 90 days. Substantial unintentional weight loss (>or=5% in any 30 days) developed in 78 residents (21%). MNT-PC dietitians were more likely to identify UWL. When UWL was identified, and, after providing nutrition care to these residents for an additional 90 days, 32 of 61 residents (52%) maintained or gained weight. Dietitians in UC and MNT-PC groups were equally successful in treating preexisting or postadmission unintentional weight loss when it was identified. Differences were found in nutrition care activities. MNT-PC dietitians reported more nutrition assessment activities, whereas UC dietitians reported more intervention activities. Conclusions/applications Nutrition care protocols with standardized weighing procedures can increase the identification of UWL in the residential healthcare environment. Improved identification supports the additional assessment activities used by MNT-PC dietitians. Similar outcomes for UC and MNT-PC groups when UWL was identified indicate that usual nutrition care was already a high standard of care for intervention.

Folic acid with or without vitamin B12 for cognition and dementia

BACKGROUND

Folates are vitamins essential to the development of the central nervous system. Insufficient folate activity at the time of conception and early pregnancy can result in congenital neural tube defects. In adult life folate deficiency has been known for decades to produce a characteristic form of anaemia ("megaloblastic"). More recently degrees of folate inadequacy, not severe enough to produce anaemia, have been found to be associated with high blood levels of the amino acid homocysteine. Such degrees of folate inadequacy can arise because of insufficient folates in the diet or because of inefficient absorption or metabolic utilisation of folates due to genetic variations. Conventional criteria for diagnosing folate deficiency may be inadequate for identifying people capable of benefiting from dietary supplementation. High blood levels of homocysteine have been linked with the risk of arterial disease, dementia and Alzheimer's disease. There is therefore interest in whether dietary supplements of folic acid (an artificial chemical analogue of naturally occurring folates) can improve cognitive function of people at risk of cognitive decline associated with ageing or dementia, whether by affecting homocysteine metabolism or through other mechanisms. There is a risk that if folic acid is given to people who have undiagnosed deficiency of vitamin B12 it may lead to neurological damage. Vitamin B12 deficiency produces both an anaemia identical to that of folate deficiency but also causes irreversible damage to the central and peripheral nervous systems. Folic acid will correct the anaemia of vitamin B12 deficiency and so delay diagnosis but will not prevent progression to neurological damage. For this reason trials of folic acid supplements may involve simultaneous administration of vitamin B12. Apparent benefit from folic acid given in the combination would therefore need to be "corrected" for any effect of vitamin B12 alone. A separate Cochrane review of vitamin B12 and cognitive function is being prepared.

OBJECTIVES

To examine the effects of folic acid supplementation, with or without vitamin B12, on elderly healthy and demented people, in preventing cognitive impairment or retarding its progress.

SEARCH STRATEGY

Trials were identified from a search of the Cochrane Dementia and Cognitive Improvement Specialized Register Group on 9 April 2003 using the terms: folic acid, folate, vitamin B9, leucovorin, methyltetrahydrofolate, vitamin B12, cobalamin, cyanocobalamin, dementia, cognitive function, cognitive impairment, Alzheimer's disease, vascular dementia, mixed dementia and controlled trials. MEDLINE and EMBASE (both all years) were searched for additional trials on healthy people.

SELECTION CRITERIA

All double-blind placebo-controlled randomized trials, in which supplements of folic acid with or without vitamin B12 were compared with placebo for elderly healthy people or people with any type of dementia or cognitive impairment.

DATA COLLECTION AND ANALYSIS

The reviewers independently applied the selection criteria and assessed study quality. One reviewer extracted and analysed the data. In comparing intervention with placebo, weighted mean differences, and standardized mean difference or odds ratios were estimated.

MAIN RESULTS

Four randomized controlled trials fulfilled the inclusion criteria for this review. One trial (Bryan 2002) enrolled healthy women, and three (Fioravanti 1997; Sommer 1998; VITAL 2003) recruited people with mild to moderate cognitive impairment or dementia with or without diagnosed folate deficiency. Fioravanti 1997 enrolled people with mild to moderate cognitive impairment or dementia as judged by scores on the Mini-Mental State Examination (MMSE) and Global Deterioration Scale and with serum folate level<3ng/l. One trial (VITAL 2003) studied the effects of a combination of vitamin B12 and folic acid on patients with mild to moderate cognitive impairment due to Alzheimer's disease or mixed dementia. The analysis from the included trials found no benefit from folic acid with or without vitamin B12 in comparison with placebo on any measures of cognition and mood for healthy or cognitively impaired or demented people: Folic acid effect and healthy participants: there was no benefit from of oral 750 mcg folic acid per day for five weeks compared with placebo on measures of cognition and mood of 19 healthy women aged 65 to 92. Folic acid effect and people with mild to moderate cognitive decline or dementia: there were no statistically significant results in favour of folic acid with or without vitamin B12 on any measures of cognitive function. Scores on the Mini-Mental State Examination (MMSE) revealed no statistically significant benefit from 2 mg per day folic acid plus 1mg vitamin B12 for 12 weeks when compared with placebo (WMD 0.39, 95% CI -0.43 to 1.21, P=0.35). Cognitive scores on the Alzheimer's Disease Scale (ADAS-Cog) showed no statistically significant benefit from 2 mg /day folic acid plus 1 mg /day vitamin B12 for 12 weeks compared with placebo (WMD 0.41, 95% -1.25 to 2.07, P=4.63). The Bristol Activities of Daily Living Scale (BADL) revealed no benefit from 2mg per day of folic acid plus 1 mg vitamin B12 for 12 weeks in comparison with placebo (WMD -0.57, 95%CI -1.95 to 0.81, P=0.42). None of the sub tests of the Randt Memory Test (RMT) showed statistically significant benefit from 15 mg of folic acid orally per day for 9 weeks when compared with placebo. One trial (Sommer 1998) reported a significant decline compared with placebo in two cognitive function tasks in demented patients who had received high doses of folic acid (10 mg /day) for unspecified periods. One trial (VITAL 2003) showed that 2 mg folic acid plus 1 mg vitamin B12 daily for 12 weeks significantly lowered serum homocysteine concentrations (P <0.0001).

REVIEWER'S CONCLUSIONS

There was no beneficial effect of 750 mcg of folic acid per day on measures of cognition or mood in older healthy women. In patients with mild to moderate cognitive decline and different forms of dementia there was no benefit from folic acid on measures of cognition or mood. Folic acid plus vitamin B12 was effective in reducing the serum homocysteine concentrations. Folic acid was well tolerated and no adverse effects were reported. More studies are needed.

Troglitazone treatment of aging Brown Norway rats improves food intake and weight gain after fasting without increasing hypothalamic NPY gene expression

Compared to younger animals, aged male Brown Norway (BN) rats demonstrate increased body fat and serum insulin, and lower prepro-neuropeptide Y (ppNPY) mRNA content in the arcuate nucleus (ARC), and blunted food intake (FI) and body weight (BW) gain in response to a 72 h fast. Since centrally administered insulin decreases FI and weight of young rats and inhibits fasting-induced increases of NPY gene expression, we hypothesized that hyperinsulinemia in old rats contributes to an age-related central dysregulation of energy balance. Young, middle-aged and old BN rats were fed chow with troglitazone (Trog; 200 mg/kg BW/d) or without drug for 75 d (Experiment 1) or 66 d (Experiment 2). Rats were then fasted for 72 h, refed for 2 weeks and sacrificed after an overnight fast (Experiment 1) or fasted for 72 h and sacrificed (Experiment 2). Serum insulin and leptin were measured from trunk blood and brains were analyzed for ppNPY mRNA by in situ hybridization. In Experiment 1, troglitazone treatment resulted in increased post-fast weight gain, rate of gain and FI in old rats. Troglitazone decreased serum insulin by 50% in old rats, while leptin levels decreased 20-30% in all age groups in Experiment 1. No differences in serum insulin or leptin were detectable with troglitazone treatment in Experiment 2, due to the extreme suppression caused by the 72 h fast. Troglitazone treatment did not increase ARC NPY gene expression either after a 72 h fast and re-feeding for 2 weeks (Experiment 1) or immediately after a 72 h fast (Experiment 2). These findings suggest that increased insulin levels may contribute to age-related impairments of FI and BW regulation. However, improvements in these defects in energy regulation induced by troglitazone do not appear to result from changes in NPY gene expression, and may be due to alterations in other hypothalamic neuropeptides that regulate energy balance.

A prospective comparison of the use of nasogastric and percutaneous endoscopic gastrostomy tubes for long-term enteral feeding in older people

OBJECTIVE

To compare the indications for and the outcome of long-term enteral feeding by nasogastric tube (NGT) with that of percutaneous endoscopic gastrostomy (PEG) tube.

DESIGN

A prospective, multicenter cohort study.

SETTING

Acute geriatric units and long-term care (LTC) hospitals in Jerusalem, Israel.

PARTICIPANTS

122 chronic patients aged 65 years and older for whom long-term enteral feeding was indicated as determined by the treating physician. Patients with acute medical conditions at the time of tube placement were excluded.

MEASUREMENTS

We examined the indications for enteral feeding, nutritional status, outcome and complications in all subjects. Subjects were followed for a minimum period of six months.

RESULTS

Although the PEG patients were older and had a higher incidence of dementia, there was an improved survival in those patients with PEG as compared to NGT (hazard ratio (HR)=0.41; 95% confidence interval (CI) 0.22-0.76; P=0.01). Also, the patients with PEG had a lower rate of aspiration (HR=0.48; 95% CI 0.26-0.89) and self-extubation (HR=0.17; 95% CI 0.05-0.58) than those with NGT. Apart from a significant improvement in the serum albumin level at the 4-week follow-up assessment in the patients with PEG compared to those with NGT (adjusted mean 3.35 compared to 3.08; F=4.982), nutritional status was otherwise similar in both groups.

CONCLUSION

In long-term enteral feeding, in a selected group of non-acute patients, the use of PEG was associated with improved survival, was better tolerated by the patient and was associated with a lower incidence of aspiration. A randomized controlled study is needed to determine whether PEG is truly superior to NGT.

Nutrition and cognitive impairment in the elderly

As the number of older people is growing rapidly worldwide and the fact that elderly people are also apparently living longer, dementia, the most common cause of cognitive impairment is getting to be a greater public health problem. Nutrition plays a role in the ageing process, but there is still a lack of knowledge about nutrition-related risk factors in cognitive impairment. Research in this area has been intensive during the last decade, and results indicate that subclinical deficiency in essential nutrients (antioxidants such as vitamins C, E and beta-carotene, vitamin B(12), vitamin B(6), folate) and nutrition-related disorders, as hypercholesterolaemia, hypertriacylglycerolaemia, hypertension, and diabetes could be some of the nutrition-related risk factors, which can be present for a long time before cognitive impairment becomes evident. Large-scale clinical trials in high-risk populations are needed to determine whether lowering blood homocysteine levels reduces the risk of cognitive impairment and may delay the clinical onset of dementia and perhaps of Alzheimer's disease. A curative treatment of cognitive impairment, especially Alzheimer's disease, is currently impossible. Actual drug therapy, if started early enough, may slow down the progression of the disease. Longitudinal studies are required in order to establish the possible link of nutrient intake--nutritional status with cognitive impairment, and if it is possible, in fact, to inhibit or delay the onset of dementia.

Can you ever be too old to be too thin? Anorexia nervosa in a 92-year-old woman

Anorexia nervosa is a common psychiatric condition that most often affects young adults. If left untreated, it can have significant morbidity and mortality.

METHODS AND DISCUSSION

In this report, we describe a woman first diagnosed with anorexia nervosa at age 92 and we discuss the relevant diagnostic and treatment-related issues.

CONCLUSION

This case underscores the need to heighten diagnostic sensitivity for this and other eating disorders at any age.

Health effect of improved meal ambiance in a Dutch nursing home: a 1-year intervention study

BACKGROUND

The aim of this study was to determine the effect of an improved ambiance of food consumption on health and nutritional status of Dutch nursing home elderly residents (n = 38) in a 1-year intervention study.

METHODS

A parallel group intervention study was performed. Improvement of ambiance focused on three points: (1) physical environment and atmosphere of the dining room, (2) food service, (3) organization of the nursing staff assistance. Dietary intake, biochemical indicators of nutritional and health status and quality of life (Sickness Impact Profile and Philadelphia Geriatric Center Moral Scale) were assessed at baseline and after 1 year of intervention. Body weight, used as an indicator of compliance and nutritional status, was assessed every 4 months.

RESULTS

Twenty-two subjects completed the 1-year intervention trial. Mean body weight significantly increased (+3.3 kg, P < 0.05) in the experimental group (n = 12), not in the control group (-0.4 kg, P = 0.78; n = 10). Health status biochemical indicators and the SIP score remained stable in the experimental group, indicating relatively stable health conditions. On the contrary, negative changes in the control group suggested a decline in health status. Dietary intake, which was insufficient at baseline, increased in both groups.

CONCLUSIONS

This study showed that improving the ambiance of food consumption is a non-negligible issue for improving nutritional status and stabilizing health of nursing home residents.

Function and regulation of cholecystokinin octapeptide, β-endorp hin and gastrin in anorexic infantile rats treated with ErBao Granules

AIM: To study the role of cholecystokinin octapeptide (CCK-8), β-endorphin (β-EP), and gastrin in an anorexic infantile rat model and no subsequent regulation of nose peptides by the Yunpi complex prescription ErBao Granule.

METHODS: We fed infantile rats with special prepared forage. A liquid extract of ErBao Granule was administered to the rats daily for 3 weeks, CCK-8, β-EP, and gastrin concentrations in hypothalamus, gastric antrum, and plasma of the rats were measured by radioimmunoassay, and were compared with controls.

RESULTS: Treatment of rats with ErBao Granule inhibited CCK-8 secretion and increased β-EP and gastrin secretion. CCK-8 concentration in hypothalamus and plasma of model control group increased significantly and correlated negatively with food intake of models, respectively. β-EP concentration in gastric antrum and plasma of model control group decreased significantly and showed a positive correlation with food intake of models, respectively. Hypothalamus concentration of β-EP was similar in models and controls. Gastrin concentration in gastric antrum of models was lower than in the blank control group, and correlated positively to food intake of models. Finally, CCK-8 concentrations in plasma of rats showed a positive correlation with plasma β-EP (r = -0.68, P < 0.05).

CONCLUSION: The increased plasma and hypothalamus concentration of CCK-8, decreased gastric antrum and plasma level of β-EP, and decreased gastric antrum concentration of gastrin are associated significantly with the anorexia of infantile anorexic rat models produced by special forage. ErBao Granule can reverse these changes, which may be the major mechanisms of ErBao Granule simulating feeding.

Flavor enhancement of food improves dietary intake and nutritional status of elderly nursing home residents

BACKGROUND

Taste and smell losses occur with aging. These changes may decrease the enjoyment of food and may subsequently reduce food consumption and negatively influence the nutritional status of elderly persons, especially those who are frail. The objective of this study was to determine if the addition of flavor enhancers to the cooked meals for elderly residents of a nursing home promotes food consumption and provides nutritional benefits.

METHODS

We performed a 16-week parallel group intervention consisting of sprinkling flavor enhancers over the cooked meals of the "flavor" group (n = 36) and not over the meals of the control group (n = 31). Measurements of intake of the cooked meals were taken before and after 8 and 16 weeks of intervention. Appetite, daily dietary intake, and anthropometry were assessed before and after the intervention.

RESULTS

On average, the body weight of the flavor group increased (+1.1 +/- 1.3 kg; p <.05) compared with that of the control group (-0.3 +/- 1.6 kg; p <.05). Daily dietary intake decreased in the control group (-485 +/- 1245 kJ; p <.05) but not in the flavor group (-208 +/- 1115 kJ; p =.28). Intake of the cooked meal increased in the flavor group (133 +/- 367 kJ; p <.05) but not in the control group (85 +/- 392 kJ). A similar trend was observed for hunger feelings, which increased only in the flavor group.

CONCLUSION

Adding flavor enhancers to the cooked meals was an effective way to improve dietary intake and body weight in elderly nursing home residents.